1. Field of the Invention
This invention relates to methods and instruments for suturing puncture wounds and more particularly to instruments for closing trocar puncture wounds formed during endoscopic and laparoscopic surgical procedures.
2. State of the Art
During laparoscopic and endoscopic surgery, one or more small incisions or punctures are made in the patient's body to provide access for one or more tubes or cannula devices. These cannulae, together with the removable puncturing devices which fit into the cannulae, are referred to as trocars. Once extended into the patient's body, the cannulae allow for insertion of various surgical instruments such as scissors, dissectors, retractors, or biopsy instruments together with an endoscope or laparoscope to perform diagnostics and/or surgery. Upon completion of the surgical procedure, the remaining trocar wounds are preferably sutured to close the wound.
Many devices and procedures have been proposed for the efficient and aesthetic closing of trocar wounds. For example, U.S. Pat. No. 5,403,329, issued Apr. 4, 1995 to Hinchcliffe, discloses an instrument for closing trocar puncture wounds having a handle assembly with a stationary portion and a movable portion; an elongated portion attached at a proximal end thereof to the stationary portion of the handle assembly; and needle deploying means associated with the elongated portion. The needle deploying means includes: an actuator member having a proximal end operably connected to the movable portion of the handle assembly and a distal end disposed adjacent a distal end of the elongated portion, the actuator member being slidable between a first position and a second position; and at least one needle carrier member mounted adjacent the distal end of the actuator member, the needle carrier being slidable relative to the actuator member upon movement thereof, between a retracted position substantially within the elongated portion and an extended position substantially without the elongated portion. The instrument also provides a suture retaining feature including at least one elongated channel disposed along the actuator member such that a length of suture may be received and retained within the channel and carried therein, between the elongated portion and the actuator member.
Although the Hinchcliffe device was an improvement over many of the devices prior to it, the Hinchcliffe device still has several disadvantages. One serious disadvantage is that the apparatus is not self-sufficient. It requires the use of forceps or other grasping tools to move needles carrying the suture material.
U.S. Pat. No. 5,462,560, issued Oct. 31, 1995 to Stevens, discloses a double needle ligature device for efficiently creating a loop suture for closing wounds, such as trocar wounds. The device preferably includes a double rod-in-needle assembly to ensure that the suture is positively held in place during needle retraction. Although the Stevens device has some advantages over the Hinchcliffe device, it still has its disadvantages. The suture must be introduced by dragging it into the abdominal cavity alongside the introducing needle. The suture must be manually threaded through the snare loop. The device is unable to secure the wound and maintain pneumoperitoneum. The device is unable to automatically position tissue relative to the needles.
U.S. Pat. No. 5,474,568, issued Dec. 12, 1995 to Scott, discloses a surgical instrument for applying sutures through body tissue including a handle assembly, an elongated housing removably mounted to said handle assembly and having a proximal end portion and a distal end portion, at least one needle carrier operatively mounted in the distal end portion and movable between a retracted position and a deployed position, and a needle releasably retained in the needle carrier member. The instrument may also include a retaining mechanism adapted to retain the at least one needle carrier in the partially deployed position. Although the Scott instrument has the advantage of being able to plug the trocar wound during closure, it has several disadvantages. It can only place a single loop suture. It has no facility for rotating or resetting.
U.S. Pat. No. 5,476,470, issued Dec. 19, 1995 to Fitzgibbons, Jr., discloses a device for suturing closed laparoscopic trocar sites to reduce the incidence of incisional herniation. A pair of needles, hollow and having an eyelet adjacent the pointed end, are secured to a clip which may be fastened over a trocar sheath (cannula). The clip is then forced to slide down the sheath and the two needles penetrate the fascia and underlying muscle surrounding the hole formed by the trocar. The needles may also be spread somewhat after passing within the skin to gain a better bite on the tissue surrounding the trocar sheath. A suture is then threaded down through one hollow needle and passed through the eyelet of the second needle, utilizing the laparoscope and a second accessory sheath. When the device is then withdrawn, the suture remains, passing through the peritoneum, muscle and fascia and may be tightened to close the site upon removal of the sheath. Though interesting in concept, the Fitzgibbons, Jr. device is difficult to operate and can only deploy a single loop of suture.
U.S. Pat. No. 5,573,542, issued Nov. 12, 1996 to Stevens, discloses a surgical tool for endoscopic suture placement which permits a surgeon to place controlled and precise internal ligatures. The tool utilizes a drive rod including an articulating or deflecting portion. When forced to an extended position, the deflecting or articulating portion forms a hook or J-shaped needle, the tip of which can be used to accurately position the suture. Although the Stevens device may be useful in some applications, it does not automatically deploy a suture, it merely aids in its deployment.
U.S. Pat. No. 5,591,180, issued Jan. 7, 1997 to Hinchcliffe, discloses an apparatus for suturing body tissue comprising first and second elongated body halves detachably connected to one another and first and second needles movable with respect to the first and second body halves. Each of the needles has a penetrating tip facing in a distal direction. At least one actuator is provided which is operatively associated with each of the first and second needles, wherein actuation of the at least one actuator advances the first and second needles into body tissue. The needles are advanced through the body tissue positioned in the window formed in each of the body halves to engage a ferrule having a suture connected thereto.
U.S. Pat. No. 5,722,981, issued Mar. 3, 1998 to Stevens, discloses a double needle ligature device for efficiently creating a loop suture for closing wounds, such as trocar wounds. The device preferably includes a double needle assembly to ensure that the suture is positively held in place during needle retraction. This patent improves upon Stevens' earlier device in that the suture is carried inside a hollow needle rather than alongside a needle. However, it still suffers from the other disadvantages of Stevens' earlier two-needle device.